Provider Demographics
NPI:1619925732
Name:RIVER VALLEY THERAPY & SPORTS MEDICINE INC
Entity Type:Organization
Organization Name:RIVER VALLEY THERAPY & SPORTS MEDICINE INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:GABE
Authorized Official - Middle Name:
Authorized Official - Last Name:FREYALDENHOVEN
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:479-968-2525
Mailing Address - Street 1:2100 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:RUSSELLVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72801-2758
Mailing Address - Country:US
Mailing Address - Phone:479-968-2525
Mailing Address - Fax:479-968-2538
Practice Address - Street 1:2100 W MAIN ST
Practice Address - Street 2:
Practice Address - City:RUSSELLVILLE
Practice Address - State:AR
Practice Address - Zip Code:72801-2758
Practice Address - Country:US
Practice Address - Phone:479-968-2525
Practice Address - Fax:479-968-2538
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-04
Last Update Date:2019-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ARDA9917OtherPALMETTO GI RAILROAD
AR5C556OtherBLUE CROSS BLUE SHIELD
AR662725OtherHEALTHLINK
ARA001OtherTRICARE
AR145301742Medicaid
ARA001OtherTRICARE
AR662725OtherHEALTHLINK
AR=========50OtherQUALCHOICE
AR145301742Medicaid